Burns Nursing Care Plan & Management

Description

Burns are caused by a transfer of energy from a heat source to the body. The depth of the injury depends on the temperature of the burning agent and the duration of contact with it.
Burns disrupt the skin, which leads to increased ﬂuid loss; infection; hypothermia; scarring; compromised immunity; and changes in function, appearance, and body image. Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns worsen the prognosis.

Characteristics of Burn

The depth of a burn injury depends on the type of injury, causative agent, temperature of the burn agent, duration of contact with the agent, and the skin thickness. Burns are classiﬁed according to the depth of tissue destruction:

Superﬁcial partialthickness burns (similar to ﬁrstdegree), such as sunburn: The epidermis and possibly a portion of the dermis are destroyed.
Deep partialthickness burns (similar to seconddegree), such as a scald: The epidermis and upper to deeper portions of the dermis are injured.
Fullthickness burns (thirddegree), such as a burn from a ﬂame or electric current: The epidermis, entire dermis, and sometimes the underlying tissue, muscle, and bone are destroyed.

Extent of Body Surface Area Burned

How much total body surface area is burned is determined by one of the following methods:

Rule of Nines: an estimation of the total body surface area burned by assigning percentages in multiples of nine to major body surfaces.
Lund and Browder method: a more precise method of estimating the extent of the burn; takes into account that the percentage of the surface area represented by various anatomic parts (head and legs) changes with growth.
Palm method: used to estimate percentage of scattered burns, using the size of the patient’s palm (about 1% of body surface area) to assess the extent of burn injury.

Causes

Most burns result from preventable accidents. Thermal burns, which are the most common type,occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries.

Gender, Ethnic/Racial, and Life Span Considerations

Preschool children account for over two-thirds of all burn fatalities. Clinicians use a special chart (Lund-Browder Chart) for children that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and in particular, young adult males ages 20 to 29 years of age, followed by children under 9 years of age. Individuals older than 50 years sustain the fewest number of serious burn injuries.

The younger child is the most common victim of burns that have been caused by liquids. Preschoolers, school-aged children, and teenagers are more frequently the victims of flame burns. Young children playing with lighters or matches are at risk, as are teenagers because of
carelessness or risk-taking behaviors around fires. Toddlers incur electrical burns from biting electrical cords or putting objects in outlets.

Most adults are victims of house fires or workrelated accidents that involve chemicals or electricity. The elderly are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat.

Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child Burns 167 experiences a burn, multiple surgeries are required to release contractures that occur as normal growth pulls at the scar tissue of their healed burns. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues. No specific gender and ethnic/racial considerations exist in burns.

Gerontologic Considerations

Elderly people are at higher risk for burn injury because of reduced coordination, strength, and sensation and changes in vision.
Predisposing factors and the health history in the older adult inﬂuence the complexity of care for the patient.
Pulmonary function is limited in the older adult and therefore airway exchange, lung elasticity, and ventilation can be affected.
This can be further affected by a history of smoking.
Decreased cardiac function and coronary artery disease increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus orother endocrine disorders present nutritional challenges and require close monitoring.
Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team.
The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal.

Primary Nursing Diagnosis

Ineffective airway clearance related to airway edema

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

Medical Management

MINOR BURN CARE. Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water 2 or 3 times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and as do all burn patients, the patient needs to receive tetanus toxoid to prevent infection.

MAJOR BURN CARE. For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social
work, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent-resuscitative, acute-wound coverage, convalescent-rehabilitative, and reorganization-reintegration.

The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. In addition to managing airway, breathing, and circulation, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition.Wounds are cleansed with chlorhexidine gluconate and care consists of silver sulfadiazine ormafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze.

The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered, through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place.

Nursing Management: Emergent/Resuscitative Phase

Assessment

Focus on the major priorities of any trauma patient; the burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues.
Assess circumstances surrounding the injury: time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma.
Monitor vital signs frequently; monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity.
Start cardiac monitoring if indicated (eg, history of cardiac or respiratory problems, electrical injury).
Check peripheral pulses on burned extremities hourly; use Doppler as needed.
Monitor ﬂuid intake (IV ﬂuids) and output (urinary catheter) and measure hourly. Note amount of urine obtained when catheter is inserted (indicates preburn renal function and ﬂuid status).
Assess body temperature, body weight, history of preburn weight, allergies, tetanus immunization, past medicalsurgical problems, current illnesses, and use of medications.
Arrange for patients with facial burns to be assessed for corneal injury.
Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partialthickness injury.
Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior.
Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support system and coping skills.